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A fit or a faint

A fit or a faint. Diagnostic Dilemma Wael B.El Sebaie . Introduction. 3% of population suffered from syncope at some times in their lives. It is very difficult to differentiate between syncopal attacks (Faints) and atonic akinetic epileptic attacks (Fits). Patients & Methods.

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A fit or a faint

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  1. A fit or a faint Diagnostic Dilemma Wael B.El Sebaie

  2. Introduction 3% of population suffered from syncope at some times in their lives. It is very difficult to differentiate between syncopal attacks (Faints) and atonic akinetic epileptic attacks (Fits)

  3. Patients & Methods 30 patients (16 females and 14 males ) with drop attacks were referred to neurology or cardiology clinic at Abo El Rish hospital (CUPH) . 10 patients at Royal Manchester hospital (RMH).

  4. All patients are subject to : • A thorough history taking • Full clinical exam • Investigations: • Laboratory studies • EEG ECG ECHO • Tilt table test done in RMH for 10 cases

  5. Tilt table test Developed during 2nd world war to study the effect of centrifugal forces on pilots during aircraft operations. Almost half century later, the head upright tilt table test, was introduced for clinical use to induce hypotension and bradycardia and confirm diagnosis of neuro-cardiogenic syncope among individuals susceptible to recurrent syncope.

  6. Despite criticism that this provocative test suffers from naïve rational lacks patients selection standards; it gains increasing popularity as a non invasive and physiologically appropriate neurophysiologic test for diagnosis of neuro-cardiogenic syncope.

  7. Results Careful history taking reveals: Presence of prodroma in 27 patients associated jerk movements in 11 enuresis in 3 sweating & enphoresis in 20 Duration of loss of consciousness: less than 1:2 minutes in 18 between 3:5 minutes in 7 more than 5 minutes in 8 Post-ictal confusion: more than 10 minutes in 3

  8. Blood pressure measurements reveals no abnormalities Lab NAD EEG Normal in 33 Abnormal in 7(2 focal,5 general) ECG Prolonged Q.T in 6 Short P.R plus U wave in 4 ECHO A.S in 3 MVP in 2 HOLTER NAD Tilt table Abnormal in 2 (out of 10)

  9. Discussion Syncope is the most common cause of transient neurological dysfunction. It affects about 15% of children. Hundreds of patients and thousands of people with syncope are miss diagnosed as epileptic. Two types of syncope are discernible : convulsive non convulsive. Patients with syncope represent 6% of medical emergency, up till now 42% remain undiagnosed {in spite of extensive sophisticated investigations}.

  10. Epilepsy is the most famous ; however not the most common paroxysmal brain disorder . Atonics Akinetic seizures are often used interchangeably to describe seizures whereas the patient suddenly falls with loss of postural tone. Reflex anoxic seizures is now used to describe non epileptic motor seizures characterized by stiffening and jerks which may accompany secondary syncope to cardiac asystole .

  11. Syncope could be classified into: Neurally mediated : Reflex, postural, autonomic Cardio vascular : Arrhythmia, structural Non cardiogenic : Epileptic, psychogenic Differentiation between these depends on history , history and history

  12. Differentiation of neuro cardiogenic syncope is based on history and clinical examination .Most authors do not recommend a full set of investigations in simple case of syncope.

  13. Complete investigations including EEG, HOLTER, Lab studies, Neuro- imaging, ECG and Echo reveal no abnormalities in 80% of cases.

  14. In our cases We depend mainly on thorough history taking to differentiate between syncope (Faints) and epileptic attacks (Fits). Lab reveals no abnormalities, EEG (17,5%) ECG , HOLTER, Echo (37,5%) Tilt table (20%).

  15. No investigations is necessary in a usual case of syncope , but repeated prolonged syncope; calls for investigations.

  16. Seizures are not provoked, except for acute symptomatic seizures and this is usually warrants no investigations Incontinence, prolonged post confusion state ,very rapid falling down are more suggestive of epileptic seizures. Neither prodroma (aura ) a unilateral jerk suggest epilepsy -Any attack with a precipitating cause is most likely not epileptic.

  17. Conclusion Differentiation between atonics Fits and Fainting attacks aimed at first to avoid misdiagnosis of syncope as epilepsy and hence prescribing unneeded antiepileptic medications for long period Syncope is usually self limited and a benign condition, and unless a definite cardiac lesion exists, requires no treatment.

  18. Vast majority of diagnostic errors is error by excess. Incorrect label of epilepsy has profound and regrettable consequences on schooling and social life beside problems of drug compliance and side effects of unneeded two years at least of antiepileptic medications.

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